Take Home Quiz For Toxicology and Endocrinology NAME - SCORE

TAKE HOME QUIZ FOR TOXICOLOGY AND ENDOCRINOLOGY
NAME_____________________________________________________SCORE______________
Drug Interferences
Complete the table:
Table: Common drug-induced modifications of clinical chemistry test values (All are dependent
upon the particular analytical methodology utilized for measurement)
ALBUMIN Causes
INCREASE
DECREASE
ALKALINE-PHOSPHATASE
INCREASE
DECREASE
AMYLASE
INCREASE
DECREASE
INCREASE
DECREASE
CALCIUM
INCREASE
DECREASE
INCREASE
DECREASE
CREATININE
INCREASE
DECREASE
INCREASE
DECREASE
DIGOXIN
INCREASE
DECRASE
INCREASE
DECREASE
PHENOBARBITAL
INCREASE
DECREASE
Be able to answer all the given cases.
Case 1
A 46-year-old male with the history of chronic back pain of 7 years duration presents to the
pain clinic seeking relief. His pain is 8-9 out of 10 and is somewhat relieved by vicodin (1 tablet
as needed) and salsalate 750 mg TID. He suffers from constipation and complains that his pain
is “burning and shooting” in nature. His internal medicine physician prescribes him 200 mg
carbamazepine BID to help relieve pain. Six weeks later his carbamazepine is increased to 600
mg BID. Two weeks after his carbamazepine is increased to 600 mg BID the patient is brought to
the emergency department by a friend who reported the patient was falling down and passing
out while at work. The patient also complained of excessive sweating and nausea. His physical
exam showed lateral nystagmus in both eyes and slight orthostasis, but was otherwise
unremarkable. In the emergency department a stat serum carbamazepine concentration was
14.4 mg/L.
1. Was the patient’s carbamazepine dosage monitored correctly?

2. Could the patient’s symptoms (dizziness, nausea, etc.) be explained by his medications?
3. Was this a preventable adverse reaction?
4. Is this a common use of carbamazepine?
5. How should this patient be treated?
6. In addition to monitoring his carbamazepine concentration what other laboratory tests
should be monitored?
Case 2
A slightly anxious 49-year-old woman with bright eyes, but no exophthalmos, presented with a
slight tremor and a diffusely enlarged thyroid gland. Her serum T 4 was 19.8 µg/dL, free T4 4.2
ng/dL and T3 660 ng/dL. The serum was positive for antimicrosomal and antithyroglobulin
antibodies.
1. What is the diagnosis for this patient?

2. Would it be useful to obtain serum TSH levels?
3. What additional test might be helpful?
Case 3
A 59-year-old woman complaining of numbness and paresthesia of her right index and ring
fingers had gained about 30 pounds the previous year. She exhibited a tired look with slight
periorbital puffiness and a diffusely enlarged thyroid (1.5 times normal size). For the last six
months she had noted dry skin, decreased energy and a change in her voice. Her heart sounds
were decreased, but there was no cardiac enlargement. Her heart rate was 56 beats per
minute, and blood pressure was 130/90 mmHg. The remainder of the physical exam was
unremarkable except that the relaxation phase of her deep tendon reflexes was delayed.
Laboratory Findings
Serum T4 2.6 µg/dL

Free T4 0.5 ng/dL
Serum TSH 110 mU/L
Serum cholesterol 375 mg/dL
Creatine Kinase 425 U/L (no increased in MB isoenzyme)
Antimicrosomal antibodies in serum Positive at 1:410,000 dilution
Antithyroglobulin antibodies in serum negative
1. What is the most likely diagnosis?

2. List other etiologies for hypothyroidism.
Case 4
A 21-year-old woman with an eight-year history of juvenile onset diabetes was brought to the
hospital in a coma. She had required 92 units of insulin daily to maintain her blood glucose
concentration in an acceptable range and prevent excessive glucosuria. On admission she had a
BP of 92/20 mmHg, a pulse of 122 beats/min, and deep respirations of 32/min. Lab data
showed:
ABG: pH =7.10 pCO2 =15 mmHg

pO2 =90 mmHg HCO3 =14 mmol/L
+
Serum Chemistry Values: Na =129 mmol/L K+ =6.4 mmol/L
-
Cl =95 mmol/L Total CO2 =5 mmol/L
glucose =1200 mg/dL urea nitrogen =74 mg/dL
creatinine =2.3 mg/dL
The serum was strongly positive for ketones.
Eight units of regular insulin were given IV and 8 units/h were given by IV infusion pump. Her
serum glucose concentration fell at a rate of approximately 100 mg/dL each hour. In seven
hours her ventilation and blood pH were normal following IV injections of NaHCO3 and vigorous
fluid and electrolyte replacement.
1. What is the nature and etiology of the acid-base disturbance?

2. Is there indication for a normal compensatory response?
3. What are serum ketones (ketone bodies)? How frequently detected?
4. Explain the abnormal serum potassium result?
5. Explain the low serum sodium result.
6. What is the cause of the low BP upon admission? How does the low BP affect GFR
(glomerular filtration rate)?
7. Calculate the patient’s anion gap. Explain.
8. Calculate the patient’s osmolality. Interpret.
Case 5
A 65-year-old obese woman is brought semi-comatose to the emergency room. She has a
history of seizures and hypertension and has been treated with phenytoin and thiazide
diuretics. She is not known to have diabetes.
On physical examination she exhibits a right hemiparesis. Initial laboratory results: plasma
glucose 1,080 mg/dL, serum sodium 144 mmol/L, potassium 4.4 mmol/L, chloride 113 mmol/L,
bicarbonate 20 mmol/L, SUN 60 mg/dL.
1. Calculate the osmolality.

2. Is the serum sodium appropriate for the degree of hyperglycemia?
3. What is the effect of the hyperosmolality on the haematocrit?
4. Do you expect ketoacidosis to be present?
5. Why are the SUN and chloride increased, and the bicarbonate decreased?

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TAKE HOME QUIZ FOR TOXICOLOGY AND ENDOCRINOLOGY

Complete the table:

1. Was the patient’s carbamazepine dosage monitored correctly?

1. What is the diagnosis for this patient?

Serum T4 2.6 µg/dL

1. What is the most likely diagnosis?

ABG: pH =7.10 pCO2 =15 mmHg

1. What is the nature and etiology of the acid-base disturbance?

1. Calculate the osmolality.

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